Abstract
Background
During peroral esophageal myotomy (POEM) for the treatment of achalasia, the optimal distal gastric myotomy length is unknown. In this study, we used a functional lumen imaging probe (FLIP) to intraoperatively measure the effect of variable distal myotomy lengths on esophagogastric junction (EGJ) distensibility.
Methods
EGJ distensibility index (DI) (minimum cross-sectional area divided by intrabag pressure) was measured with FLIP after each operative step. Each patient’s myotomy was performed in four increments from proximal to distal: (1) an esophageal myotomy (from 6 cm proximal to the EGJ to 1 cm proximal to it), (2) a myotomy ablating the lower esophageal sphincter (LES) complex (from 1 cm proximal to the EGJ to 1 cm distal to it), (3) an initial gastric extension (from 1 cm distal to the EGJ to 2 cm distal), and (4) a final gastric extension (from 2 cm distal to the EGJ to 3 cm distal).
Results
Measurements were taken in 16 achalasia patients during POEM. POEM resulted in an overall increase in DI (pre 1.2 vs. post 7.2 mm2/mmHg, p < .001). Initial creation of the submucosal tunnel resulted in a threefold increase in DI (1.2 vs. 3.6 mm2/mmHg, p < .001). When the myotomy was then performed in a stepwise fashion from proximal to distal, the initial esophageal myotomy component had no effect on DI. Subsequent myotomy extension across the LES complex resulted in an increase in DI, as did the initial gastric myotomy extension (to 2 cm distal to the EGJ). The final gastric myotomy extension (to 3 cm distal) had no further effect.
Conclusions
During POEM, creation of the submucosal tunnel prior to myotomy resulted in a marked improvement in EGJ physiology. Myotomy extension across the LES complex and to 2 cm onto the gastric wall resulted in the normalization of EGJ distensibility, whereas subsequent extension to 3 cm distal to the EGJ did not increase compliance further.
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Acknowledgments
This work was supported by R01 DK56033 (PJK) and R01 DK092217 (JEP) from the Public Health Service. The authors would like to acknowledge Rowena Martinez, RN, and Colleen Krantz, RN, for their help in coordinating the clinical aspects of this study.
Disclosures
Nathaniel Soper is on the scientific advisory boards of TransEnterix and Miret Surgical, which are unrelated to this study. Eric Hungness receives an honorarium for educational activities from Baxter, which is unrelated to this study. Ezra Teitelbaum, Joel Sternbach, Rym El Khoury, John Pandolfino, Peter Kahrilas, and Zhiyue Lin have no conflicts of interest or financial ties to disclose.
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Teitelbaum, E.N., Sternbach, J.M., El Khoury, R. et al. The effect of incremental distal gastric myotomy lengths on EGJ distensibility during POEM for achalasia. Surg Endosc 30, 745–750 (2016). https://doi.org/10.1007/s00464-015-4269-8
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DOI: https://doi.org/10.1007/s00464-015-4269-8